An Unusual Etiology of Severe Right Heart Failure Deserving of Wider Recognition.

A previously healthy 31-year-old man presented with worsening shortness of breath and a petechial rash. Echocardiography showed severe right-sided heart failure with midsystolic notching of the antegrade right ventricular outflow Doppler envelope suggesting pulmonary hypertension. An extensive work-up revealed scurvy, with a dramatic resolution of symptoms shortly after vitamin C supplementation.

Subaortic Membrane Mimicking Hypertrophic Cardiomyopathy in the Setting of Mitral Valve Infective Endocarditis.

Infective endocarditis (IE) can present in a wide spectrum of systemic signs and symptoms. Here we report a case of a patient who presented with a headache. Upon further investigation, the patient was found to have mitral valve IE. This likely led to a subarachnoid hemorrhage secondary to a ruptured mycotic aneurysm. In this case report, we emphasize the importance of noticing early neurological signs of IE even when initial imaging is negative for aneurysmal formation. Further, this patient had a subaortic membrane (SAoM) mimicking the sonographic appearance of hypertrophic obstructive cardiomyopathy. Remarkably, SAoM is usually associated with aortic valvular pathology; however, this patient unusually presented with mitral valve involvement.

Methotrexate Toxicity: A Simple Solution to a Complex Problem.

Methotrexate is a highly effective medication that is the mainstay of treatment for numerous complex dermatological and rheumatological disorders. However, its use requires close monitoring as it has serious side effects that could be fatal if not recognized promptly. Herein, we present an interesting case of methotrexate toxicity leading to a prolonged hospital stay with resultant increase in health care cost and patient dissatisfaction. It remains of pivotal importance for primary care physicians and hospitalists to be aware of its side effect profile. As such, early recognition of methotrexate toxicity can result in earlier initiation of goal-directed therapies, leading to improved outcomes and shorter hospital stay. Patient education and effective communication between health care providers and the patient are of utmost importance in ensuring patient safety.

Treatment of severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and coronavirus disease 2019 (COVID-19): a systematic review of in vitro, in vivo, and clinical trials.

Rationale: Coronavirus disease 2019 (COVID-19) has spread worldwide and poses a threat to humanity. However, no specific therapy has been established for this disease yet. We conducted a systematic review to highlight therapeutic agents that might be effective in treating COVID-19. Methods: We searched Medline, Medrxiv.org, and reference lists of relevant publications to identify articles of in vitro, in vivo, and clinical studies on treatments for severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19 published in English until the last update on October 11, 2020. Results: We included 36 studies on SARS, 30 studies on MERS, and 10 meta-analyses on SARS and MERS in this study. Through 12,200 title and 830 full-text screenings for COVID-19, eight in vitro studies, 46 randomized controlled trials (RCTs) on 6,886 patients, and 29 meta-analyses were obtained and investigated. There was no therapeutic agent that consistently resulted in positive outcomes across SARS, MERS, and COVID-19. Remdesivir showed a therapeutic effect for COVID-19 in two RCTs involving the largest number of total participants (n = 1,461). Other therapies that showed an effect in at least two RCTs for COVID-19 were sofosbuvir/daclatasvir (n = 114), colchicine (n = 140), IFN-ß1b (n = 193), and convalescent plasma therapy (n = 126). Conclusions: This review provides information to help establish treatment and research directions for COVID-19 based on currently available evidence. Further RCTs are required.

Rare and Fascinating Case of ST-Elevation Myocardial Infarction Diagnosis From an Underlying Ventricular Paced Rhythm.

This is a case of a patient diagnosed with anterior ST-elevation myocardial infarction (STEMI) with a ventricular paced rhythm after the patient underwent a femoral-femoral bypass surgery for severe peripheral vascular disease. The case highlights the diagnosis of STEMI in the setting of paced rhythm in the appropriate clinical setting.

Pseudoaneurysm Leading to Aortic Dissection: An Interesting Case Presentation.

This is an interesting case of ascending penetrating aortic ulcer (PAU) leading to pseudoaneurysm and eventually type A aortic dissection and peri-aortic hematoma. PAUs are common clinical manifestations, however, uncommonly lead to pseudoaneurysms that cause aortic dissection.

Association of Pretransplant Skin Cancer With Posttransplant Malignancy, Graft Failure and Death in Kidney Transplant Recipients.

BACKGROUND: Posttransplant malignancy (PTM) is one of the leading causes of late death in kidney recipients. Those with a cancer history may be more prone to develop a recurrent or a new cancer. We studied the association between pretransplant skin cancer, PTM, death, and graft failure. METHODS: Primary adult kidney recipients transplanted between 2005 and 2013 were included. Malignancy information was obtained from Organ Procurement Kidney Transplant Network/United Network for Organ Sharing registration and follow-up forms. Posttransplant malignancy was classified into skin cancer, solid tumor, and posttransplant lymphoproliferative disorder (PTLD). Competing risk and survival analysis with adjustment for confounders were used to calculate risk for PTM, death and graft failure in recipients with pretransplant skin cancer compared with those without cancer. Risk was reported in hazard ratios (HR) with 95% confidence interval (CI). RESULTS: The cohort included 1671 recipients with and 102 961 without pretransplant skin malignancy. The 5-year cumulative incidence of PTM in patients with and without a pretransplant skin cancer history was 31.6% and 7.4%, respectively (P < 0.001). Recipients with pretransplant skin cancer had increased risk of PTM (sub-HR [SHR], 2.60; 95% CI, 2.27-2.98), and posttransplant skin cancer (SHR, 2.92; 95% CI, 2.52-3.39), PTLD (SHR, 1.93; 95% CI, 1.01-3.66), solid tumor (SHR, 1.44; 95% CI, 1.04-1.99), death (HR, 1.20; 95% CI, 1.07-1.34), and graft failure (HR, 1.17; 95% CI, 1.05-1.30) when compared with those without pretransplant malignancy. CONCLUSIONS: Pretransplant skin cancer was associated with an increased risk of posttransplant skin cancer, PTLD, solid organ cancer, death and graft failure.

Pretransplant malignancy as a risk factor for posttransplant malignancy after heart transplantation.

BACKGROUND: Posttransplant malignancy is a major cause of death in orthotopic heart transplant recipients. Our study objective is to identify whether pretransplant malignancy increases the risk for posttransplant malignancy. METHODS: Using the Organ Procurement and Transplantation Network/United Network for Organ Sharing database, adult (≥18 years old) recipients of a primary orthotopic heart transplant performed between 2000 and 2012 were included. The cohort was stratified according to the presence and type of pretransplant malignancy. Outcomes were posttransplant overall, skin, solid malignancies, and posttransplant lymphoproliferative disorder. Incidence of and time to first posttransplant malignancy, accounting for death as a competing event, were calculated. Fine and Gray competing risks regression was performed to examine risk factors associated with posttransplant malignancy. RESULTS: Of 23,171 recipients, overall posttransplant malignancy was diagnosed in 2673 recipients (11.5%).The median time to overall, skin, solid posttransplant malignancies, and posttransplant lymphoproliferative disorder were 3.2 (1.6-5.7), 3.2 (1.7-5.6), 3.5 (1.7-5.9), and 2.5 years(0.8-5.2), respectively. Pretransplant malignancy increased the risk of posttransplant overall (subhazard ratio [SHR], 1.51; 95% confidence interval [95% CI], 1.27-1.81), skin (SHR, 1.55, 95% CI, 1.23-1.93), and solid organ malignancies (SHR, 1.54; 95% CI, 1.13-2.11). Pretransplant skin malignancy increased the risk of posttransplant skin malignancy (SHR, 2.79; 95% CI, 1.82-4.28). Pretransplant solid malignancy also increased the risk of posttransplant skin malignancy (SHR, 1.55; 95% CI, 1.07-2.25) but not of posttransplant solid tumors (SHR, 1.23; 95% CI, 0.69-2.19). Older, male, and white were also risk factors for posttransplant malignancy. CONCLUSIONS: A history of any pretransplant malignancy was associated with increased risks of skin and solid malignancies after transplantation. The specific type of posttransplant malignancy risk differed according to the type of pretransplant malignancy.